INFECTION AND IMMUNOLOGIC IN CORNEA AND SCLERA

Infection and Immunologic Div. - Ophthalmology Dept. Medicine Faculty Brawijaya Univ. / Saiful Anwar Hospital Malang 2009

ANATOMY

Cornea

CORNEA
KERATITIS
Symptom
Pain has many pain fibers; worsened by movement of the lids Photophobia the result of painful contraction of an inflamed iris dilation of iris vessels is a reflect phenomenon caused by irritation of the corneal nerve ending Tearing

Corneal sensitivity test

Vital Dye Staining

Sign
Superficial lesions
1. Punctate epithelial erosion (PEE) Sign : Tiny, epithelial defect that stain with fluorescein 2. Punctate epithelial Keratitis (PEK) Sign : granular, opalescent, swollen epithelial cells.

3. Mucus Filaments Sign: Mucus strands lined with epithel , attached at one and two the corneal surface; the unattached and moves with each blink

4. Epithelial edema Sign: characterized by loss of normal corneal lustre, if severe maybe associated with vesicles and bullae

5. Superficial neovascularization Sign: a feature of chronic ocular surface irritation or hypoxia as in contact lens wear

6. Pannus Sign: non specific term that is usually applied to

superficial neovascularization accompanied by

degenerative sub epithelial change extending centrally from the limbus

Deep lesions

1. Infiltrates
Focal areas of active stromal inflammation composed of accumulation of leucocytes and cellular debris Sign: focal, granular, grey white opacities usually within the anterior stroma and associated with limbal

or conjunctival hyperemia. A surrounding halo of

less dense infiltration such that individual inflammatory cells maybe discernible.

2. Ulceration
Do to melting of the connective tissue in response to the release of enzimes from endogenous sources in response to inflammation or from exogenous organism (bacteria, amoebae and fungi)

Epithelial defect , stromal loss, stromal

inflammation.

3. Vascularization
the venous blood vessel are easily seen, whereas the arterial feeding vessels are smaller and require high magnification.

4. Folds in descemet membrane (striate keratopathy) Maybe caused by surgical trauma ocular hypotony and stromal inflammation

Principles of Treatment
Control of infection and inflammation
1. Antimicrobial agents 2. Topical steroids 3. Systemic immunosuppressive agents Promotion of healing 1. Lubrication

SCLERA
EPISCLERITIS
Simple episcleritis
Predominantly affects females. It has a great tendency to recur either in the same eye or sometimes both together

Diagnosis
1. Presentation : sudden, the eye red and uncomfortable within an hour of the start of an attack. Pain is unusual but if it occurs it is localized to the eye it self and does not irradiate to the face or temple

2. Signs :
Redness may vary from a mild to a fiery red flush, and maybe sectoral or diffuse

The attack reaches its peak within 12 hours and

then gradually fades over the next 10 21 days

Treatment
1. First attack. Topical steroid; artificial tears 2. Recurrent attack. NSAID systemic

Nodular episcleritis
Young females but has a less acute on set and a more prolonged course than simple episcleritis

Diagnosis
1. Presentation : a red eye typically first noted on waking

2. Signs :

one or more tender nodule, almost always within the

interpalpebral fissure. Instillation of 10% phenylephrine drops will decongest the conjunctival and episcleral vessel Self limiting

Treatment
1. First attack : topical steroid intensive
2. Recurrent attack : NSAID

SCLERITIS

Characterized by edema and cellular infiltration of the entire thickness of the sclera

Anterior Non Necrotizing Scleritis

Diffuse 1. Presentation : ocular redness followed a few days later by

aching and pain with may spread to the face and temple
2. Signs Vascular congestion and dilatation associated with edema The redness maybe generalized or localized to one

quadrant
Scleral translucency

Complications
Cornea
1. Acute infiltrative stromal keratitis 2. Sclerosing keratitis 3. Pheripheral ulcerative keratitis

Other complications
1. Uveitis
2. Uveal effusion 3. Glaucoma 4. Hypotony 5. Perforation

Treatment
1. Topical steroid
2. Systemic NSAID 3. Periocular steroid injection 4. Systemic steroid 5. Cytotoxic agents

6. Immune modulators

DRY EYE DISORDERS

DEFINITIONS :
Inadequate tear volume or function

Unstable tear film and ocular surface disease

1. Keratoconjunctivitis sicca (KCS) refers to any eye with some degree of dryness 2. Xerophthalmia DE Vit. A def 3. Xerosis keratinization conj. cicatrization 4. Sjogren syndrome autoimmune inflammatory disease

PHYSIOLOGY
Tear Film Constituents

Spread of the tear film (TF) Spread over the ocular surface through

neuronallly control blinking mechanism.

For effective resurfacing TF o Normal blink refflect

o Contact between external ocular surface and

eyelid o Normal corneal epithelium

CLINICAL FEATURES
Symptoms
Dryness, grittiness, burning, discharge, transient,
blurring of vision, redness, crusting of lid.

Sign
1. Posterior blepharitis and MGD 2. Conjunctiva : mild keratinization, redness

The Bulbar Conjunctiva Localized hyperemia

Lip like fold of the inferior conjunctiva

Foam in meibomian seborrhoea

Mucus plaques and a few filaments stained with rose bengal

A dry spot caused by tear film break up

Typical epithelial erosions

Superficial punctate keratopathy

Corneal Dellen

CLINICAL DIAGNOSTIC TEST Measurement of tear secretion Schirmer Test

Assessment of lacrimal gland function Schirmer Test Without topical anesthesia Abnormal: <5mm/ 5minute

With topical anesthesia

Abnormal : <10 mm/ 5minute

KORNEA
Transparan/jernih : Avaskuler, struktur uniform, deturgesens Nutrisi : difusi glukosa dari COA O2 dari tear film kornea perifer dari O2 sirkulasi limbal Sensori nerve ending : Via N.V divisi I, ekstensi dari N.ciliaris longus dan membentuk plexus saraf di stroma dan sub epitel, unmyelinated

1. Epitel

Sel epitel skuamosa stratified Epitel dan tear film optical smooth surface Tight junction antara sel epitel superfisial mencegah penetrasi airmata masuk stroma Sel-sel pada permukaan mengandung mikrovili fasilitas penyerapan musin Regenerasi (+) scar (-)

2. Membrana Bowman
Lap. aseluler jernih Fibril kolagen Bila rusak regenerasi (-)

3. Stroma 90 % tebal kornea T/D serabut kolagen sel keratocyt

Sabut kolagen paralel teratur transparan 4. Membrana Descemet Lap. Terkuat ; tidak mudah ditembus T/D serat kolagen jernih Membrana basemen endotel kornea 5. Endotel T/D 1 lapis sel heksagonal

Bila rusak Regenerasi (-) Kerusakan permanen

KERATITIS
Distribusi : difus, fokal, multifokal
Kedalaman : epitel, sub epitel, stromal, endotel Lokasi : sentral, perifer

Bentuk infiltrat : dendrit, disciform, numular, geografika, pungtata dll

FISIOLOGI GEJALA Sakit / nyeri kornea banyak serabut saraf Fotofobi pembuluh darah iris dilatasi, kontraksi iris yang meradang Blefarospasme karena rasa sakit yang diperhebat oleh gesekan palpebra (superior) Epifora rangsang nyeri reflek air mata meningkat Kabur : karena kornea berfungsi sebagai jendela mata bila infiltrat di sentral Pada umumnya tidak ada kotoran mata, kecuali pada ulkus bakteri purulen

TANDA KLINIS kelainan kornea

I. Superfisial 1. Epiteliopati pungtata (bukan tanda spesifik ) Erosi epitel pungtata dengan karakteristik : Grey white spot, tiny, slightly depressed Tes Fluoresin positip Keratitis epitel pungtata (merupakan tanda infeksi virus) Granular opalescent epithelial cell Tes Fluoresin positip

2. Edema Epitel Vesikel, bula

3. Filamen kornea Lapisan mukous yang menempel pada reseptor abnormal Tes Rose Bengal positip

4. Pannus Jaringan fibrovaskuler dari limbus sub epitel Arkade vessel > 1 2 mm batas dari limbus

II. Tanda Klinis di stroma dan membrana descemet 1. Infiltrat stromal Akumulasi leukosit dan debris seluler, indikasi peradangan aktif, bercak warna kelabu, batas tidak jelas Di-slit lamp : opasitas granular lokal

2. Edema stromal

Co-exist dengan infiltrasi peradangan

3. Vaskularisasi stromal

4. Folds in descemet membrane

Pada peradangan stromal, trauma surgical, hipotomi ocular

Keratitis Bakteri
Faktor predisposisi: Trauma, lensa kontak, perubahan struktur permukaan kornea dll
Gejala Klinis :

Visus , fotofobi, nyeri, nrocoh, merah, blefarospasme, discharge, edema palpebra

Tanda Klinis : Inj. konjungtiva (CI) dan Inj. Perikorneal (PCVI) Infiltrat, edema stromal, hipopion, keratik presipitat (Kips)

Bila progresif Ulkus Kornea Defek epitel, infiltrat stroma dengan batas tidak jelas, edema stroma lipatan descemet Endotel plaque, Kips, sel, flare, hipopion, descemetocele, perforasi. Diagnosis etiologi : Kerokan kornea dan pemeriksaan mikrobiologi gram, kultur, uji resistensi

Prinsip terapi : 1. Antibiotika topikal broad spectrum Dual terapi : kombinasi 2 antibiotik ( Fortified) Monoterapi : fluoroquinolon 2. Ciprofloxacin oral 2 x 750 mg (bila meluas ke sklera) 3. Obat penunjang : sikloplegi, anti glaukoma , analgesik

Keratitis Jamur / Fungal / Keratomikosis

Faktor predisposisi: Trauma tumbuh-tumbuhan ( area agriculture) dan kayu Terapi steroid topikal, penderita immunocompromise, pre-exist penyakit kornea

Gejala klinis :

Kabur, sakit kepala, sensasi benda asing, discharge,

tidak akut

Tanda klinis : Greyish, infiltrat stromal dengan dry texture

surrounding, satelit, feathery, immune ring infiltrate, plaque endotel, hipopion. Terapi :

Topikal Natamycin 5%, Amphotericin B (0.15 0.3 %)

Oral Itraconazole 200 mg/hari

Keratitis Virus Herpes Simplek (HSV)

Basic concept :
HSV I : 90% populasi seropositif HSV I antibodi Subklinis predominan infeksi (wajah, bibir, mata) HSV II: Inf. Venereal acquired (herpes genital) Jarang ke mata 1. Infeksi primer Pada anak, subklinis atau URI, fever.

2. Infeksi rekuren
Virus axon saraf sensori ganglion N.V bentuk laten

Virus reaktivasi axon saraf sensori target tissue

(herpetik keratitis)

Tanda klinis infeksi okuler primer - skin vesicle - Unilat. Blefarokonjungtivitis dan rekuren : - keratitis epitel - keratitis stromal

- konjungtivitis follicular

- iridocyclitis

Keratitis Herpes Zoster Ophthalmicus

Causa : V. Zoster Vi (VZV)

Patogenesa :
stlh terserang Varicella dorman di sensori root ganglia

Reaktivasi & migrasi ke saraf sensori kulit & mata

Kerusakan okuler (meknsm concomittan)

Invasi Vi lgsg Radang sekunder konjungtivitis, keratitis epitel keratitis stromal, uveitis, skleritis Hipoesthesia keratitis neurotropik

Resiko keterlibatan okuler

N. V div opthalmic HZO N. Nasal external (Hutchinson sign) Insidensi : dekade 60-70 th

Terapi

: - acyclovir 800 mg 5 x 1 (7 10 hr)

- Corticosteroid, sikloplegik

Immune Mediated Disease Of The Sclera and Episclera

EPISKLERITIS self limited, srg rekuren, sistemik<<<, usia muda Gejala : merah unilat, discomfort, perih, watering
Tanda :
a. episkleritis simpel : Sering, sembuh spontan 1-2 mgg b. episkleritis noduler : lokal, raised

Terapi : - tanpa terapi membaik - NSAID oral, lubrikan - vasokontriktor - steroid topikal

Skleritis
Edema dan infiltrasi seluler di seluruh ketebalan sklera Mengancam visus Causa : - sistemik - surgery induced - infectious (dr ulkus kornea)

Klasifikasi : 1. skleritis anterior

- non necrotic : difusa, nodular

- necrotic : radang (+)/(-) 2. skleritis posterior

Gejala klinis : nyeri

Tanda klinis : distorsi pattern vasc. radial normal nodul imobile

Komplikasi skleritis
Keratitis perifer, uveitis, katarak, glaukoma, sklera thinning

Lab penyakit sistemik

Konsul internis, rheumatologi Terapi :

Kortikosteroid topikal, oral, IV

NSAID oral Imunosupresif

3. Tear film

4. Cornea

5. Complication

SCHIRMER TEST

Aqueous tear production

With or without topical anaesthesia The filter paper is folded 5 mm from one end and inserted at the junction of the middle and outer third of the lower lid, not to touch the cornea or lashes

The patient is asked to keep the eyes gently closed

After 5 minutes the filter paper is removed and the amount of wetting from the fold measured

< 10 mm without anaesthesia

< 6 mm with anaesthesia

Abnormal

TREATMENT
Patient education Tear substitutes